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Nursing HomeMedicaid

Royal Oaks Manor-Bradbury Oaks

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

1763 Royal Oaks Drive, Duarte, CA 9101048 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
4.3/5

based on 37 Google reviews

5
4
3
2
1
Royal Oaks Manor-Bradbury Oaks Nursing Home in Duarte, CA — Street View
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What this means for your family

This facility is an excellent choice for seniors seeking a beautiful, socially active environment with high-quality amenities. However, families should closely monitor the quality of dining and be prepared to advocate for consistent care standards, as some long-term residents have noted a decline in food and service since recent management changes.

Google Reviews

Google Reviews

37 reviews on Google
Royal Oaks is highly regarded for its beautiful, serene campus and its vibrant social community, with many long-term residents praising the sense of belonging. While many families find the staff kind and attentive, there are notable concerns regarding a decline in service quality and food standards following management changes.

Quality Themes

Tap a score for details
Food3.0Staff7.0Clean5.0Activities9.0MedsN/AMemoryN/AComms4.0Value3.0

Strengths

  • Beautiful, serene campus grounds
  • Engaged and social community atmosphere
  • Welcoming and friendly front-line staff
  • Excellent amenities and amenities

Concerns

  • Decline in food quality and dining standards (mentioned by 2 reviewers)
  • Decline in overall service quality following management changes (mentioned by 2 reviewers)
  • Unprofessional behavior by specific nursing staff

Rating Trends

Tap a year to see what changed

234'17(6)'19(3)'21(7)'23(13)'25(14)'26(5)

Distribution · 82 analyzed

5
63
4
7
3
0
2
0
1
12

How They Respond to Reviews

100%response rate
Good

The owner provides personalized responses that frequently reference the reviewer's name and specific details from their feedback. For negative or critical reviews, they use a consistent professional template that directs the reviewer to the Executive Director for direct resolution.

Questions for Your Tour

  • 1The campus grounds look so beautiful and serene; what kind of outdoor activities or strolls are available for residents to enjoy the scenery?
  • 2I noticed the management is very responsive to feedback; how does the leadership team work with families to address any changes in service or care quality?
  • 3Could you tell me a bit more about the current dining program and how you ensure meal quality and variety remain consistent for everyone?
  • 4What is the protocol for handling medical emergencies or urgent care needs during the overnight hours?
  • 5How do the staff members foster that social, engaged community atmosphere that people often mention when visiting?
  • 6With the recent changes in management, what steps are being taken to ensure communication between the nursing staff and family members remains clear and frequent?

Personalized based on this facility's data


Key Review Excerpts

Royal Oaks has a stunning campus of 15+ acres with California Live Oak trees and horses grazing across the road! Beautiful facilities! Friendly and interesting people with whom we've become close in just a couple of years!

Long-term resident · 2024★★★★★

One of the first things I notice when entering the building is that it doesn’t have the ‘smell’ that I’ve encountered in so many facilities like this. It is beautifully appointed, landscaped well and the overall physical aspect of the facility is very pleasant.

Visitor to skilled nursing area · 2021★★★★★

My parents moved into RO in 2021, and have had some health issues in the last year that have required me to have quite a bit of interaction with the Royal Oaks and Bradbury Oaks staff. I have found every individual working there to be extremely kind, attentive, and considerate.

Family of resident · 2023★★★★★
Source: 37 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.54hrs
72%
Registered nurses for medical care
Total Nursing
4.74hrs
OK
All nurses + aides combined
Staff Turnover
28%
Lower is better (< 30% = good)
RN Turnover
44%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

6

measures

Worse Than Avg

9

measures

Mixed Results

2

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility34.4%
Worse than Avg
Here
34.4%
US
19.4%
CA
10.7%
Los angeles
9.7%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility32.4%
Worse than Avg
Here
32.4%
US
15.3%
CA
10.5%
Los angeles
9.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility5.1%
Better than Avg
Here
5.1%
US
19.5%
CA
13.7%
Los angeles
10.8%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility20.7%
Worse than Avg
Here
20.7%
US
15.5%
CA
11.7%
Los angeles
11.4%
😔

Residents with depression symptoms

↓ Lower is better
This Facility3.3%
Better than Avg
Here
3.3%
US
12.1%
CA
7.0%
Los angeles
8.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility19.0%
Worse than Avg
Here
19.0%
US
14.4%
CA
10.4%
Los angeles
12.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility93.9%
Better than Avg
Here
93.9%
US
79.8%
CA
93.2%
Los angeles
92.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility90.3%
Mixed vs Avgs
Here
90.3%
US
81.8%
CA
94.2%
Los angeles
94.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.0%
Worse than Avg
Here
2.0%
US
1.6%
CA
1.5%
Los angeles
1.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

10deficiencies
1penalties
Near state avg (15.4)
6 complaint-triggered

This facility has a concerning pattern with families filing complaints that led to 6 deficiency findings, indicating ongoing care issues that prompted external reports. The most recurring problems involve medication management, accident prevention and safety, and treatment and care delivery according to resident needs. While all deficiencies show correction dates, the persistence of similar issues across multiple surveys—particularly safety hazards and medication errors—suggests systemic challenges that families should carefully evaluate during visits.

Jan 2, 2026Routine
9
0578Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Dec 1, 2025Complaint
2
0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0919Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Nov 15, 2024Routine
18
0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0700Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0919Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Oct 5, 2024Complaint
1
0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

May 10, 2024Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Apr 15, 2024Complaint
1
0744Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Federal Penalties

Payment Denial

Apr 15, 2024

15-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Royal Oaks Manor-Bradbury Oaks

Organization Type

nonprofit

Chain Affiliation

Chain Name

Humangood

Chain Size

17 facilities nationwide

Chain avg rating: 4.3/5 · Rank 16 of 17

Ownership & Management

Owners

Humangood Socal

Owner · Organization

100%

Humangood

Owner (parent company) · Organization

100%

Key personnel

U.s. Bank5% or Greater Security InterestBaker, JudithOfficer / DirectorBattison, WilliamOfficer / DirectorBrown, HermanOfficer / DirectorChristopherson, JoanneOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

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